Provider Demographics
NPI:1982762761
Name:GROTH, STEPHEN JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JOHN
Last Name:GROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:554 DIAMOND ST
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-3404
Mailing Address - Country:US
Mailing Address - Phone:949-306-7383
Mailing Address - Fax:949-497-1141
Practice Address - Street 1:554 DIAMOND ST
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-3404
Practice Address - Country:US
Practice Address - Phone:949-306-7383
Practice Address - Fax:949-497-1141
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2012-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36991207P00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G369910Medicaid
CA00G369910Medicaid
CAB55834Medicare UPIN